MEDICARE: EASTPORT PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336L0003X	Long Term Care Pharmacy
4	3336S0011X	Specialty Pharmacy
5	3336C0003X	Community/Retail Pharmacy	PH28441	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2146100	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316346620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTPORT PHARMACY LLC

Provider Business Mailing Address
First Line	:	8972 S US HIGHWAY 1
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-3403
Country	:	US
Telephone Number	:	772-800-7267
Fax Number	:	772-800-7265

Provider Business Practice Location Address
First Line	:	8972 S US HIGHWAY 1
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-3403
Country	:	US
Telephone Number	:	772-800-7267
Fax Number	:	772-800-7265

Authorized Official
Title or Position	:	OWNER, MGR, PIC
Name	:	HASSAN BAZZI
Credential	:	RPH
Telephone Number	:	772-324-1512

Provider Enumeration Date	:	08/22/2014
Last Update Date	:	02/26/2015

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Directions to “EASTPORT PHARMACY LLC ” Practice Location

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